Normal ECG

normal sinus rhythm

o o o o o o each P wave is followed by a QRS P waves normal for the subject P wave rate 60 - 100 bpm with <10% variation rate <60 = sinus bradycardia rate >100 = sinus tachycardia variation >10% = sinus arrhythmia

normal QRS axis normal P waves

o height < 2.5 mm in lead II o width < 0.11 s in lead II o for abnormal P waves see right atrial hypertrophy, left atrial hypertrophy, atrial premature beat, hyperkalaemia

 normal PR interval
o 0.12 to 0.20 s (3 - 5 small squares) o for short PR segment consider Wolff-Parkinson-White syndrome or Lown-Ganong-Levine syndrome (other causes - Duchenne muscular dystrophy, type II glycogen storage disease (Pompe's), HOCM) o for long PR interval see first degree heart block and 'trifasicular' block

normal QRS complex

o < 0.12 s duration (3 small squares) o for abnormally wide QRS consider right or left bundle branch block, ventricular rhythm, hyperkalaemia, etc. o no pathological Q waves

no evidence of left or right ventricular hypertrophy

 normal QT interval
o Calculate the corrected QT interval (QTc) by dividing the QT interval by the square root of the preceeding R - R interval. Normal = 0.42 s.
o o o o o o Causes of long QT interval myocardial infarction, myocarditis, diffuse myocardial disease hypocalcaemia, hypothyrodism subarachnoid haemorrhage, intracerebral haemorrhage drugs (e.g. sotalol, amiodarone) hereditary o Romano Ward syndrome (autosomal dominant) o Jervill + Lange Nielson syndrome (autosomal recessive) associated with sensorineural deafness

 normal ST segment
o no elevation or depression
o causes of elevation include acute MI (e.g. anterior, inferior), left bundle branch block, normal variants (e.g. athletic heart, Edeiken pattern, high-take off), acute pericarditis o causes of depression include myocardial ischaemia, digoxin effect, ventricular hypertrophy, acute posterior MI, pulmonary embolus, left bundle branch block

 normal T wave
o causes of tall T waves include hyperkalaemia, hyperacute myocardial infarction and left bundle branch block o causes of small, flattened or inverted T waves are numerous and include ischaemia, age, race, hyperventilation, anxiety, drinking iced water, LVH, drugs (e.g. digoxin), pericarditis, PE, intraventricular conduction delay (e.g. RBBB)and electrolyte disturbance.

normal U wave

Ischemic Heart Disease

A 55 year old man with 4 hours of "crushing" chest pain

Acute inferior myocardial infarction

ST elevation in the inferior leads II, III and aVF Reciprocal ST depression in the anterior leads

A 63 year old woman with 10 hours of chest pain and sweating

Acute anterior myocardial infarction

ST elevation in the anterior leads V1 - 6, I and aVL reciprocal ST depression in the inferior leads

A 60 year old woman with 3 hours of chest pain

Acute posterior myocardial infarction

(hyperacute) the mirror image of acute injury in leads V1 - 3 (fully evolved) tall R wave, tall upright T wave in leads V1 -3 usually associated with inferior and/or lateral wall MI

A 53 year old man with Ischaemic Heart Disease

Old inferior myocardial infarction

a Q wave in lead III wider than 1 mm (1 small square) and a Q wave in lead aVF wider than 0.5 mm and a Q wave of any size in lead II

Hypertrophic Pattern

An 83 year old man with aortic stenosis

Left ventricular hypertrophy (LVH)

There are many different criteria for LVH Sokolow + Lyon (Am Heart J, 1949;37:161)
S V1+ R V5 or V6 > 35 mm

Cornell criteria (Circulation, 1987;3: 565-72)

SV3 + R avl > 28 mm in men SV3 + R avl > 20 mm in women

Framingham criteria (Circulation,1990; 81:815-820)

R avl > 11mm, R V4-6 > 25mm S V1-3 > 25 mm, S V1 or V2 + R V5 or V6 > 35 mm, R I + S III > 25 mm

Romhilt + Estes (Am Heart J, 1986:75:752-58)

Point score system

Left atrial abnormality (dilatation or hypertrophy)

M shaped P wave in lead II prominent terminal negative component to P wave in lead V1 (shown here)

A 75 year old lady with loud first heart sound and mid-diastolic murmur

Mitral Stenosis
Atrial fibrillation:
No P waves are visible. The rhythm is irregularly irregular (random).

Right ventricular hypertrophy:

Right axis deviation Deep S waves in the lateral leads Dominant R wave in lead V1 (not shown here)

The combination of Atrial Fibrillation and Right Axis Deviation on the ECG suggests the possibility of mitral stenosis.

Atrio-Ventricular (AV) block

An 84 year old lady with hypertension

 left anterior hemiblock

QRS axis more left than -30 degrees initial R wave in the inferior leads (II, III and aVF) absence of any other cause of left axis deviation

left ventricular hypertrophy

In the presence of left anterior hemiblock the diagnostic criteria of LVH are changed. Rosenbaum suggested that an S wave in lead III deeper than 15 mm as predictive of LVH.

long PR interval (also called first degree heart block)

PR interval longer than 0.2 seconds

 left atrial hypertrophy

M shaped P wave in lead II P wave duration > 0.11 seconds terminal negative component to the P wave in lead V1

A 73 year old woman with dizziness

2 to 1 AV block
every other P wave is conducted to the ventricles
2 to 1 AV block starts after the 5th QRS in this 3 channel recording. The first non-conducted P wave is indicated with an arrow.

the PR interval of conducted P waves is constant

in this lady there is a long PR interval (and left bundle branch block)

2 to 1 AV block cannot be classified into Mobitz type I or II as we do not know if the 2nd P wave would be conducted with the same or longer PR interval

A 70 year old man with exercise intolerance

Complete Heart Block

P waves are not conducted to the ventricles because of block at the AV node. The P waves are indicated below and show no relation to the QRS complexes. They 'probe' every part of the ventricular cycle but are never conducted. The ventricles are depolarised by a ventricular escape rhythm

An 82 year old lady with dizzy spells

Atrial fibrillation and complete heart block

Fibrillary waves of atrial fibrillation and no P waves. Regular ventricular rhythm The wider the QRS of the ventricular escape rhythm the less reliable the escape mechanism. AF with complete heart block can be easily missed and is an indication for a permanent pacemaker

Bundle Branch Block (BBB)

A 55 year old man with 4 hours of "crushing" chest pain

Right Bundle Branch Block

wide QRS, more than 120 ms (3 small squares) secondary R wave in lead V1 other features include slurred S wave in lateral leads and T wave changes in the septal leads

An 84 year old lady with hypertension

 left anterior hemiblock

QRS axis more left than -30 degrees initial R wave in the inferior leads (II, III and aVF) absence of any other cause of left axis deviation

left ventricular hypertrophy

In the presence of left anterior hemiblock the diagnostic criteria of LVH are changed. Rosenbaum suggested that an S wave in lead III deeper than 15 mm as predictive of LVH.

long PR interval (also called first degree heart block)

PR interval longer than 0.2 seconds

left atrial hypertrophy

M shaped P wave in lead II P wave duration > 0.11 seconds terminal negative component to the P wave in lead V1

A 79 year old man with 5 hours of chest pain

Acute myocardial infarction in the presence of left bundle branch block

Features suggesting acute MI
ST changes in the same direction as the QRS (as shown here) ST elevation more than you'd expect from LBBB alone (e.g. > 5 mm in leads V1 - 3) Q waves in two consecutive lateral leads (indicating anteroseptal MI)
Sgarbossa EB et al, N Engl J Med 1996;334:481-7

A 90 year old lady with syncope

'Trifasicular' block
Complete Right Bundle Branch Block Left Anterior Hemiblock Long PR interval
The combination of RBBB, LAFB and long PR interval has been called 'trifasicular' block and implies that conduction is delayed in the third fascicle (in this case the left posterior fascicle) and a permanent pacemaker may be needed. However there are other causes of a long PR interval such as delayed conduction in the AV node or atrium so 'trifascicular block' is not a true ECG diagnosis.

Supraventricular Rhythms

A 55 year old man with 4 hours of "crushing" chest pain

Sinus bradycardia
P wave rate of less than 60 bpm the rate in this example is about 45 bpm Acute inferior MI and Right Bundle Branch Block are also present.

A 34 year old lady with asthma

Sinus tachycardia
P wave rate greater than 100 bpm

A 60 year old man with hypertension

Atrial Bigeminy
each beat is followed by an atrial premature beat

A 76 year old man with breathlessness

Atrial fibrillation with rapid ventricular response

Irregularly irregular ventricular rhythm. Sometimes on first look the rhythm may appear regular but on closer inspection it is clearly irregular.

A 68 year old lady on digoxin complaining of lethargy

Atrial flutter
A characteristic 'sawtooth' or 'picket-fence' waveform of an intra-atrial re-entry circuit usually at about 300 bpm.
This lady was taking rather too much digoxin and has a very slow ventricular response.

An 57 year old lady with palpitations

Atrial flutter with 2:1 AV conduction

The sawtooth waveform of atrial flutter can usually be seen in the inferior leads II, III and aVF if one looks closely. Sometimes the rapid atrial rate can be seen in V1. Suspect atrial flutter with 2:1 block when you see a rate of about 150 bpm. The atrial rate is shown to be twice the ventricular rate in the figure below.

See also atrial flutter with slow ventricular response.

A 47 year old man with a long history of palpitations and, lately, blackouts

Wolf-Parkinson-White syndrome with atrial fibrillation

irregularly irregular, wide complex tachycardia impulses from the atria are conducted to the ventricles via either both the AV node and accessory pathway producing a broad fusion complex or just the AV node producing a narrow complex (without a delta wave) or just the accessory pathway producing a very broad 'pure' delta wave people who develop this rhythm and have very short R - R intervals are at higher risk of V

Ventricular Rhythms

A lady with Romano-Ward syndrome

Long QT interval
QT interval normally varies with heart rate - becoming shorter at faster rates. It is usually corrected using the cycle length (R-R interval) as shown opposite. normal QTc = 0.42 seconds
Romano-Ward syndrome is an autosomal dominantly inherited form of long QT interval and there is a risk of recurrent ventricular tachycardia, particularly Torsade de Pointes.

Ventricular premature beats (VPBs)

2 ventricular premature beats are also shown in this ECG They are
broad occur earlier than normal and are followed by a full compensatory pause (the distance between the normal beats before and after the VPB is equal to twice the normal cycle length

A 70 year old man with exercise intolerance

Complete Heart Block

P waves are not conducted to the ventricles because of block at the AV node. The P waves are indicated below and show no relation to the QRS complexes. They 'probe' every part of the ventricular cycle but are never conducted. The ventricles are depolarised by a ventricular escape rhythm

A 60 year old man with Ischaemic Heart Disease

Polymorphous ventricular tachycardia (Torsade de pointes)

This is a form of VT where there is usually no difficulty in recognising its ventricular origin. wide QRS complexes with multiple morphologies changing R - R intervals the axis seems to twist about the isoelectric line it is important to recognise this pattern as there are a number of reversible causes
heart block hypokalaemia or hypomagnesaemia drugs (e.g. tricyclic antidepressant overdose) congenital long QT syndromes

other causes of long QT (e.g. IHD)

A 36 year old lady with recurrent blackouts

Implantable cardioverter defibrillator

Most of this 12-lead recording is polymorphic ventricular tachycardia but, in the rhythm strip, the large deflection (arrowed) is the defibrillator discharging. Following the defibrillation a dual chamber pacemaker can be seen

A 72 year old man with a permanent pacemaker

Ventricular pacemaker
pacing spikes (best seen here in V4 - V6) will be seen - they may be subtle the paced QRS complexes are abnormally wide
In this example the pacemaker starts when there is a long R - R interval following a blocked atrial premature beat (arrowed in figure below). Sinus rhythm takes over again later in the rhythm strip.

A 56 year old man with breathlessness and raised JVP

Pericardial effusion with electrical alternans

The QRS axis alternates between beats. In this example it is best seen in the chest leads where the QRS points in different directions! This is rarely seen and is due to the heart moving in the effusion.

A 40 year old woman with pleuritic chest pain and breathlessness

Acute pulmonary embolus

an S1Q3T3 pattern a prominent S wave in lead I a Q wave and inverted T wave in lead III sinus tachycardia T wave inversion in leads V1 - V3 Right Bundle Branch Block low amplitude deflections

A 58 year old man on haemodialysis presents with profound weakness after a weekend fishing trip

Hyperkalaemia
small or absent P waves atrial fibrillation wide QRS shortened or absent ST segment wide, tall and tented T waves ventricular fibrillation

This man's serum potassium was 9.6 mmol/L

A 22 year old lady with prolonged vomiting

Hypokalaemia
small or absent T waves prominent U waves (see diagram) first or second degree AV block slight depression of the ST segment

This lady's serum potassium was 1.8 mmol/L

A 64 year old lady on digoxin

Digitalis effect
shortened QT interval characteristic down-sloping ST depression, reverse tick appearence, (shown here in leads V5 and V6) dysrhythmias
ventricular / atrial premature beats paroxysmal atrial tachycardia with variable AV block ventricular tachycardia and fibrillation many others